State dissociation moderates response to dialectical behavior therapy for posttraumatic stress disorder in women with and without borderline personality disorder

Abstract

BackgroundPatients with posttraumatic stress disorder (PTSD) are prone to dissociation, which in theory should interfere with successful treatment. However, most empirical studies do not substantiate this assumption.ObjectiveThe primary objective was to test whether state dissociation predicts the success of an adaptation of dialectical behavior therapy designed for the treatment of patients with PTSD after childhood sexual abuse (CSA) (DBT-PTSD). We further explored whether the operationalization of dissociation as state versus trait dissociation made a difference with respect to prediction of improvement.MethodsWe present a hypothesis-driven post hoc analysis of a randomized controlled trial on the efficacy in patients with PTSD after CSA. Regression analyses relating pre–post improvements in the Clinician-Administered PTSD Scale (CAPS) and the Posttraumatic Diagnostic Scale (PDS) to dissociation were applied to the women who participated in the active treatment arm (DBT-PTSD). Multivariate models accounting for major confounders were used to relate improvements in both the CAPS and the PDS to (1) state dissociation as assessed after each treatment session and (2) trait dissociation as assessed at baseline.ResultsState dissociation during psychotherapy sessions predicted improvement after DBT-PTSD: patients with low state dissociation during treatment had a higher chance to show substantial improvement. This relation consistently emerged across subgroups of PTSD patients with and without borderline personality disorder. The operationalization of dissociation as state versus trait dissociation made a difference as improvement was not significantly predicted from trait dissociation.ConclusionsDissociation during treatment sessions may reduce success with trauma-focused therapies such as DBT-PTSD. Accordingly, clinical studies aimed at improving ways to address dissociation are needed.Highlights of the articleThe article investigates whether state dissociation during psychotherapeutic sessions moderates the success of an established treatment for PTSD.Patients were much more likely to substantially improve with respect to PTSD symptomatology if state dissociation during psychotherapeutic sessions was low.The article suggests that the relation between low dissociation and good response in highly symptomatic patients is stronger than previously thought.Future studies investigating the extent to which outcome might be improved when treating dissociation more vigorously than usually are necessary.

Perspectives on the conceptualization of the dissociative subtype of PTSD and implications for treatment

“…Moreover, given that dissociation tends to be correlated with PTSD severity, and that this association was not controlled for, results may be due to greater baseline PTSD severity as opposed to dissociation. Finally, a study of dissociation during psychotherapy sessions (“state dissociation”) in a modified version of Dialectical Behavior Therapy (DBT), found that patients with less session-to-session dissociation were more likely to demonstrate PTSD symptom reductions [54]. That study used a change-score analytic design and additionally controlled for baseline PTSD symptoms.…”

“…Distinguishing effects of dissociation from those of baseline PTSD is critical, however this analytic approach was problematic because baseline PTSD contributed both to the exogenous covariate and to the endogenous change score—a form of criterion contamination that complicates interpretation of results. Nonetheless, studies of acute (state) dissociation [53–54] raise the possibility that such symptoms may evidence differential effects on PTSD treatment response relative to trait dissociation, suggesting that additional research on this topic is necessary. This is particularly true given experimental evidence that acute dissociation may impede emotional learning [55], a critical component of PTSD treatment.…”

Trauma-related altered states of consciousness in post-traumatic stress disorder patients with or without comorbid dissociative disorders

“…Lanius (2015) further outlines how the model could guide treatment for trauma-affected patients, as TRASC of different dimensions of consciousness may require different treatments, something that future clinical studies could investigate. Studies on the impact of dissociation on treatment show inconsistent results, with some studies finding dissociation to predict poorer response (Bae, Kim, & Park, 2016; Kleindienst et al, 2016) while others fail to find such an effect (Minnen & Harned, 2012; Zoet, Wagenmans, van Minnen, & de Jongh, 2018). Heterogeneity in how dissociation is measured and conceptualized may influence the results, making it important to investigate whether experiences of TRASC affect treatment outcome; such an evaluation is planned for the present randomized controlled trial.…”

Tagesklinische dialektisch-behaviorale Therapie: Eine Verlaufsuntersuchung nach Entlassung. Gibt es Prädiktoren für eine Verschlechterung?

“…Aber auch in einer randomisierten kontrollierten Studie reduzierten komorbide Dissoziationen während der DBT bei BPS und gleichzeitig vorliegender PTBS deren Therapieerfolg [Kleindienst et al, 2016]. Bedics et al [2015] konnten an 101 Frauen mit einer BPS über eine 1-JahresSpanne zeigen, dass die Stärke der therapeutischen Allianz die Suizidalität beeinflusst und damit auch den Therapieerfolg.…”